Chest Pain (Outpatient)

OSCE
Clinical Scenario - Chest Pain in the Clinic (Outpatient)
55 year old male comes to your clinic due to 2 episodes of chest pain

Vital Signs:

● BP: 145/90 mmHg

Objective: Focused & relevant history & medical exam. Explain P.E findings.
Self Notes Prior to Entering the Room
Case Notes: Starting Consultation:

● Patient name & Age ● Introduce yourself to the patient and the
● C/C: Chest Pain nurse (if present)
● Objective: Hx and P.E ● Wash/Sanitize hands
● History: Details about pain, cardiovascular ● Confirm patient identity
risk factors ● Ask the patient how they would like to be
● P.E: CVS, Resp, G.I addressed
● DDx: Angina, ACS, GERD, Costochondritis ● Ask the patient how they can be helped
today
History Objectives:

1. HOPI
2. Past medical Hx
3. Family Hx
4. Current Medications and Allergies
5. Social History
History
HOPI Other Important Questions for HOPI
● How many times has this happened before?
1. [S] Where is the pain? “In my chest”
● Did you feel like your heart was racing?
2. [O] What were you doing when the pain
started? “While I was walking outside” ● Did you feel out of breath? Shortness of breath?
3. [C] What does the pain feel like? “My chest ● Any fever, wheezing, cough, cough with blood, or
felt heavy and tight” heartburn?
4. [R] Does the pain go anywhere else? “No” ● How long did you walk before the pain started?
5. [A] Any associated symptoms like ● Have you ever lost consciousness?
nausea/vomiting/sweating/dizziness? “a little ● Have you ever had any blurriness of vision?
nausea and sweating”
● Have you ever received treatment for this issue
6. [T] How long did you have this pain? “A
couple minutes” before?
7. [E] Is there anything you do that make the
pain better or worse? “It improved when I
stopped to breathe, worse if I walked faster”
8. [S] How severe is this pain from 1-10? “7”
 History Medication and Allergy Hx:
1. You mentioned that you have high blood pressure, do you take
any medication for it?
PMHx ○ “No, I try to control it with my diet and exercise”
○ Ask the patient if they have any apprehensions about
● Have you ever been diagnosed with any medical conditions? taking any medications or if they have tried any
○ High blood pressure medications in the past to control their blood pressure
● Do you have diabetes, high cholesterol or any heart disease? 2. Have you taken any OTC medications?
○ Patient may or may not know about their cholesterol 3. Do you know if you have any allergies to any medications?
● Have you ever been hospitalized or had any surgery? 4. Do you have any food allergies?
○ No in this case 5. Do you take any herbal supplements?

Social Hx:
FMHx: Inform the patient that you will be asking some personal questions
about their life and ask if it is okay to proceed.
1. Has anyone in your family had a heart attack?
1. What do you do for work?
○ Patient mentions their father who died at 63 years old a ○ Do you enjoy your work?
couple years ago ○ Does your work ever stress you out?
○ Pause consultation and acknowledge their passing and 2. Who do you live with?
○ Inquire about their health as well
ask how they have dealt with the loss and how it has ○ Ask if they have any children
affected their life “I understand how difficult that may be, 3. Do you smoke?
how are you dealing with that” 4. Do you drink alcohol?
5. Do you use any recreational drugs?
2. Has anyone in your family suddenly died? 6. Do you exercise?
○ No 7. Tell me about your diet?
3. Are there any diseases diagnosed in your family?
○ No Closing the Hx:
Thank you for sharing this information with me, it seems like your pain is likely angina. I
would like to examine you if that's okay and we will likely need to do some tests. Do you
have any questions?
 Head to Toe CVS Examination:
● Head/Face: Look for mouth dehydration & central cyanosis, check eyes for pallor & jaundice
● Neck: Palpate carotid bruit, check for the JVP
● Precordium:
○ Inspection: Observation of the chest wall and palpation of the point of maximal impulse (PMI). The PMI is typically
palpated at the 5th intercostal space in the mid-clavicular line, but is shifted laterally in dilated cardiomyopathy.
Check for any chest wall deformities, scars or pacemakers
○ Auscultation: Apex, tricuspid, mitral, pulmonic & B/L carotids. Listen for S1 & S2, murmurs, thrills & bruits
● Chest: Look for pulsations, scars, deformities, dilated veins & skin changes. Ask the patient to take a deep breath, look
for symmetrical chest expansion. Feel for the apical beat located normally in the 5th intercostal space, midclavicular line.
Feel for any heaves or thrills. Listen for the heart sounds (S1, S2, S3, S4) and for any murmurs. Ask the patient to
breathe in and out, listen for bilateral vesicular breath sounds in all the lung fields, listen for any crackles or wheeze
● Back: Auscultate lung base for any crackles for pulmonary edema
● Arms: Check if brachial & radial pulse are regular, collapsing and if it is symmetrical by comparing the radial pulse from
both arms
● Hands: Look for nicotine stains, peripheral cyanosis, palmar erythema, clubbing and capillary refill
● Abdomen: Inspect for visible pulsations & scars. Palpate abdominal aorta above the umbilicus, auscultate on either
sides of the umbilicus for aortic iliac bruits
● Pelvis: Palpate the femoral artery bilaterally & check for radial-femoral delay (sign of aortic coarctation)
● Lower Limbs: Look for peripheral cyanosis, warmth, redness, or cool and clammy extremities, edema, capillary refill,
numbness or tingling. Palpate lower limb pulses (dorsalis pedis, posterior tibial artery). Check for a positive Homans's
sign (calf pain at dorsiflexion of the foot) for DVT
● Ankles: Inspect the toes, feet, and legs bilaterally, noting color, warmth, movement, sensation, capillary refill, hair
distribution and peripheral edema
Rapid CVS Physical Examination
Inspect:
● Face, lips, and extremities for pallor or cyanosis
● Neck for jugular vein distension (JVD) in upright position or with head of bed at 30-45 degree angle
● Chest for deformities and wounds/scars on chest
● Bilateral arms/hands, noting color, warmth, movement, sensation (CWMS), edema, and color of nail beds
● Bilateral legs, noting CWMS, edema to lower legs and feet, presence of superficial distended veins, and color of nail
beds
Auscultate:

● Using both the bell and the diaphragm of the stethoscope over five auscultation areas of the heart.
● Auscultate the apical pulse at the fifth intercostal space, midclavicular line for one minute.
● Note the rate and rhythm.
● Identify the S1 and S2 sounds and follow up on any unexpected findings (e.g., extra sounds or irregular rhythm).

Palpate:

● Radial, brachial, dorsalis pedis, and posterior tibialis pulses bilaterally.